Pediatr Surg Int (1996) 11:374-377 © Springer-Verlag 1996 R. Kataria • S. Agarwala • D. K. Mitra • G. Kaur T. K. Chattopadhyay • C. S. Bal • P. S. N. Menon Primary hyperparathyroidism in children Accepted: 17 July 1995 Abstract Primary hyperparathyroid- ism is an uncommon condition in childhood that is easily amenable to surgical treatment with excellent re- sults. Pathologically, the parathyroid glands may show generalized hyper- plasia or, more commonly, adenoma formation, the latter frequently being seen in adolescence. Two girls with solitary parathyroid adenomas and pre- dominantly skeletal manifestations re- sembling tickets are reported, under- lining the need to suspect and appro- priately investigate these children. The literature on the subject is reviewed. Key words Primary hyperparathyr- oidism • Childhood • Parathyroid adenoma R. Kataria • S. Agarwala • D. K. Mitra (~) Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi - 110029, India G. Kaur • R S. N. Menon Department of Pediatrics, All India Institute of Medical Sciences, New Delhi - 110029, India T. K. Chattopadhyay Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi - 110029, India C. S. Bal Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi - 110029, India Introduction Primary hyperparathyroidism (PHPT) remains a rare disorder in childhood despite widespread use of automated serum calcium (Ca) and phosphate (Ph) measurements, with only about 100 cases reported in the English lit- erature in children less than 16 years of age [7, 15]. The clinical effects of HPT are due to elevated serum Ca levels, which in turn are a result of raised circulating parathyroid hormone (PTH). Unlike adults, children have limited causes for raised serum Ca levels other than HPT. These include vitamin D intoxication, malignancy, sarcoidosis, hypothyroidism, and fa- milial hypocalciuric hypercalcemia [24]. Raised PTH levels confirm the diagnosis of HPT. Pathologically, the parathyroid glands may show diffuse hyperplasia or, more commonly, ade- nomas invariably involving a single gland. Two cases of PHPT in children caused by solitary parathyroid adeno- mas are described, highlighting the clinical spectrum of the disease. Case reports Case 1. A 13-year-old girl was referred with a history of recurrent episodes of pain in both lower limbs for 15 months and generalized weakness over the previous 6 months. Genu varum had been noted for the last 1 year, although it had not been progressive. She had received.vitamin D (vit. D) prior to referral on a presumptive diagnosis of rickets based on radiologic exancfinations of her hands, wrists, Fig. 1 Computed tomography scan showing parathyroid adenoma (arrow) on left side and knees. There was no family history of endocrine or skeletal disorders. The girl was normotensive and well-nour- ished, with a weight of 50 kg and height 134 cm. Besides the genu varum, she had no other bony deformities or stigmata of tickets. No nodules were palpable in the neck. Her cardiopulmonary, abdominal, and neurologi- cal examinations were essentially normal. Her serum Ca ranged from 3.0 to 3.3 retool/1 (normal 2.20-2.50 retool/l), Ph 0.71- 0.83 mmol/1 (0.95-1.75 mmol/1), albumin 47 g/l, creatinine (Cr) 44.2 gmol/1, and alka- line phosphatase (alk phos) 3,600-4,000 IU/1 (30-120 IU/1). Serum PTH (C-terminal assay) ranged from 105.3 to 121.3 pmol/1 (normal 5.4-22.8 pmol/1); 24-h urinary Ca and Ph excretion were in the normal range while on a normocalcemic diet for 3 consec- utive days (Ca 2.8-3.15 retool/day and Ph 8.2-10.1 mmol/day). An ultrasound (US) scan of the neck failed to show any abnorm- ality. Computerized tomography (CT) of the neck and superior mediastinum revealed a 2-cm-diameter nodule posterior to the left lobe of the thyroid gland (Fig. 1). Thallium- technetium subtraction scintigraphy con- firmed the presence of a solitary left parathyr- oid adenoma (Fig. 2).